Evidence Based Interventions for Shoulder Pain: Difference between revisions

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== Introduction ==
== Introduction ==
A wide range of both conservative and surgical interventions are currently used to treat shoulder pain. Multiple systematic reviews relating to the effectiveness of interventions for shoulder pain have been published. As a result of this expansive secondary evidence-base, the purpose of this review is to systematically retrieve, appraise and synthesize findings from previous systematic reviews to help understand how knowledge has developed over time and what research currently tells us about the management of this common condition.  
A wide range of both conservative and surgical interventions are currently used to treat shoulder pain. Multiple systematic reviews relating to the effectiveness of interventions for shoulder pain have been published.  


== Education ==
== Education ==

Revision as of 23:15, 4 February 2018

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Rachael Lowe, Kim Jackson, Rucha Gadgil, Robin Tacchetti, Simisola Ajeyalemi, Haseeb Ur Rehman and Lucinda hampton  

Introduction[edit | edit source]

A wide range of both conservative and surgical interventions are currently used to treat shoulder pain. Multiple systematic reviews relating to the effectiveness of interventions for shoulder pain have been published.

Education[edit | edit source]

Education plays a great role in the management of individuals with shoulder pain. The physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient and providing biomechanical information about the shoulder that is not evidence-based can add to their concerns. It is important to avoid reinforcing individuals fears about the threatening processes that might be going on as these fears or concerns can act as a barrier to recovery and need to be properly addressed. An essential component of treatment for individuals with shoulder pain is to encourage active self-management. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. Advice can be effectively supported by offering simple evidence-based educational materials.

Exercise Therapy[edit | edit source]

There are few studies about the efficacy of conservative treatment. Even though current evidence is not sufficient to allow definitive conclusions on conservative treatment is commonly treated non-operatively with therapeutic exercise therapy. The results of randomized controlled trials and systematic reviews of interventions varied findings but do suggest that exercise may be an effective treatment for overall shoulder pain, and a structured exercise program is unequivocally the main intervention specifically for Rotator Cuff related Shoulder Pain, while consensus on dosage, frequency, method of delivery, acceptable pain tolerance, inter-exercise activity levels, and specific exercise inclusion has not been achieved.[1][2][3][4] There is a definite need for well-planned randomized controlled trials investigating the efficacy of exercise in the management in specific shoulder conditions.

Level 2 - Confidence A

  • Effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). – Green, S; Buchbinder, R; Hetrick, S , Cochrane Review, updated Feb. 2009
  • Effective for pain reduction and function restoration in impingement (11 trials) [5]

Passive Treatments[edit | edit source]

Evidence suggests that passive treatment modalities such as manual therapy, electrotherapy, taping should be avoided as mono-therapy but can in some instances provide some additional benefit when utilised in conjunction with therapeutic exercise programs. The effectiveness of passive treatment modalities may be both modality and condition specific. [6]

Manual Therapy[edit | edit source]

Evidence suggests that Manual Therapy, broadly defined as "..the use of hands in a curative and healing manner or a hands-on technique with therapeutic intent..." is beneficial for at least some patients with shoulder pain, is more effective when used in combination with exercise but has limited evidence as a stand alone treatment option. Manual Therapy refers to manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues). Multiple reports in recent peer-reviewed literature suggest that manipulative techniques aimed at cervico-thoracic and thoracic spine, used in conjunction with exercise produce superior benefits in patients with subacromial and/or rotator cuff related shoulder pain. The quality of evidence in this area is limited and further research is warranted to determine the extent and nature of the relationship between thoracic manipulation and shoulder pain.

Level 2 - Confidence B

  • Benefits appear to be mostly short term and about the same as injection[7]
  • High Grade better than Long Grade in the long-term, End-range and MWM better than Mid-range[8]
  • Mobilisation plus Exercise better than Exercise alone, but only at the shortest follow-up[8]
  • For manual therapy in general with common shoulder disorders, excluding neurogenic disorders [9]

The following Case Studies examine the role of Manual Therapy on Shoulder Pain;

Taping[edit | edit source]

Kinesiotape[edit | edit source]

Level 2 - Confidence D

  • Kinesio Tape vs. Sham in 42 subjects - Did not help impingement pain [10]
  • 17 baseballers with impingement pain - Increased post scap tilt @ 30 & 60 elevation AND increase lower trap activity in the 60-30 lowering range [11]

Electrotherapy Modalities[edit | edit source]

Electrical stimulation agents and thermal agents are most often used in physiotherapy for pain management. However, non-thermal agents, such as pulsed ultrasound, have been reported as having an analgesic effect. There is limited evidence for efficacy of most electrotherapy modalities in the managment of shoulder back pain.

Laser[edit | edit source]

Systematic reviews consistently conclude that the evidence does not support the effectiveness of laser therapy compared to other interventions.[12] While Low Level Laser does not appear to have strong evidence as a stand alone treatment, there is limited evidence to suggest that Low Level Laser reduces pain and is a viable pain-modifying treatment and consequently may accelerate improvement of physical function, possibly by controlling inflammation or stimulating tendon repair, with the end result being reduced pain and more rapid improvement when added to an exercise-based treatment programme. It has also been suggested that Low Level Laser may have a more pronounced effect on shoulder function if the benefit of pain relief is used specifically to optimize parameters of exercise. [13] Research also suggests that Low Level Laser treatment is a safe and effective pain treatment option in comparison to Corticosteroid Injection, particularly for Rotator Cuff Tendinopathy, and as such should be offered before proceeding with Injection Therapy.[12][13] Further high quality trials are required to determine the effect of laser, in particular directly compared with pharmaceuticals. [7][13]

Level 2 - Confidence B

  • Low Level Laser to Placebo showed significantly better shoulder function at end of treatment (p < 0.0001) [13]
  • Low Level Laser Superior to Sham Low Level Laser
  • Short term (2 Week Benefit) vs. Placebo RR 3.71 (1.89-7.28) [7]

Ultrasound[edit | edit source]

Currently multiple systematic reviews do not support the effectiveness of ultrasound when utilised for subacromial or rotator cuff related shoulder pain.[12]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Haahr JP, Andersen JH. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8-years' follow-up in a prospective, randomized study. Scand J Rheumatol. 2006;35:224-8.
  2. ↑ Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, et al. No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five- year results of a randomised controlled trial. Bone & joint research. 2013;2:132-9.
  3. ↑ Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, et al. Treatment of non- traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The bone & joint journal. 2014;96-B:75-81.
  4. ↑ Lewis J. Rotator cuff related shoulder pain: assessment, management and uncertainties. Manual therapy. 2016 Jun 1;23:57-68.
  5. ↑ Kuhn, John E. "Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol." Journal of shoulder and elbow surgery 18.1 (2009): 138-160.
  6. ↑ Yu H, Côté P, Shearer HM, Wong JJ, Sutton DA, Randhawa KA, Varatharajan S, Southerst D, Mior SA, Ameis A, Stupar M. Effectiveness of passive physical modalities for shoulder pain: systematic review by the Ontario protocol for traffic injury management collaboration. Physical therapy. 2015 Mar 1;95(3):306-18.
  7. ↑ 7.0 7.1 7.2 Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database systematic Review The Cochrane library. 2006;3.
  8. ↑ 8.0 8.1 Favejee, M. M., B. M. A. Huisstede, and B. W. Koes. "Frozen shoulder: the effectiveness of conservative and surgical interventions—systematic review." British journal of sports medicine 45.1 (2011): 49-56.
  9. ↑ Brantingham, James W., et al. "Manipulative therapy for shoulder pain and disorders: expansion of a systematic review." Journal of manipulative and physiological therapeutics 34.5 (2011): 314- 346.
  10. ↑ Thelen, Mark D., James A. Dauber, and Paul D. Stoneman. "The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial." journal of orthopaedic & sports physical therapy 38.7 (2008): 389-395.
  11. ↑ Hsu, Yin-Hsin, et al. "The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome." Journal of electromyography and kinesiology 19.6 (2009): 1092-1099.
  12. ↑ 12.0 12.1 12.2 Littlewood C, May S, Walters S. A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy. Shoulder & Elbow. 2013 Jul 1;5(3):151-67.
  13. ↑ 13.0 13.1 13.2 13.3 Haslerud S, Magnussen LH, Joensen J, Lopes‐Martins RA, Bjordal JM. The efficacy of low‐level laser therapy for shoulder tendinopathy: a systematic review and meta‐analysis of randomized controlled trials. Physiotherapy Research International. 2015 Jun 1;20(2):108-25.
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